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Nathan M, Newburger JW, Bell M, Tang A, Gongwer R, Dunbar-Masterson C, Atz AM, Bacha E, Colan S, Gaynor JW, Kanter K, Levine JC, Ohye R, Pizarro C, Schwartz S, Shirali G, Tani L, Tweddell J, Gurvitz M. Development of the Residual Lesion Score for congenital heart surgery: the RAND Delphi methodology. Cardiol Young 2022; 33:1-14. [PMID: 36562256 DOI: 10.1017/s1047951122003791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND AND OBJECTIVE The Residual Lesion Score is a novel tool for assessing the achievement of surgical objectives in congenital heart surgery based on widely available clinical and echocardiographic characteristics. This article describes the methodology used to develop the Residual Lesion Score from the previously developed Technical Performance Score for five common congenital cardiac procedures using the RAND Delphi methodology. METHODS A panel of 11 experts from the field of paediatric and congenital cardiology and cardiac surgery, 2 co-chairs, and a consultant were assembled to review and comment on validity and feasibility of measuring the sub-components of intraoperative and discharge Residual Lesion Score for five congenital cardiac procedures. In the first email round, the panel reviewed and commented on the Residual Lesion Score and provided validity and feasibility scores for sub-components of each of the five procedures. In the second in-person round, email comments and scores were reviewed and the Residual Lesion Score revised. The modified Residual Lesion Score was scored independently by each panellist for validity and feasibility and used to develop the "final" Residual Lesion Score. RESULTS The Residual Lesion Score sub-components with a median validity score of ≥7 and median feasibility score of ≥4 that were scored without disagreement and with low absolute deviation from the median were included in the "final" Residual Lesion Score. CONCLUSION Using the RAND Delphi methodology, we were able to develop Residual Lesion Score modules for five important congenital cardiac procedures for the Pediatric Heart Network's Residual Lesion Score study.
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Affiliation(s)
- Meena Nathan
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, MA, USA
- Department of Surgery, Harvard Medical School, Boston, MA, USA
| | - Jane W Newburger
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Margaret Bell
- Department of Cardiac Psychiatry Research Program, Massachusetts General Hospital, Boston, MA, USA
| | - Alexander Tang
- Department of Pediatrics, Johns Hopkins University, Baltimore, MD, USA
| | | | | | - Andrew M Atz
- Division of Pediatric Cardiology, Medical University of South Carolina, Charleston, SC, USA
| | - Emile Bacha
- Division of Cardiothoracic Surgery, New York-Presbyterian/Morgan Stanley Children's Hospital, Columbia University Irving Medical Center, New York, NY, USA
| | - Steven Colan
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - J William Gaynor
- Division of Cardiac Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Kirk Kanter
- Division of Pediatric Cardiac Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Jami C Levine
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Richard Ohye
- Division of Pediatric Cardiac Surgery, C. S. Mott Children's Hospital, Ann Arbor, MI, USA
| | - Christian Pizarro
- Division of Cardiac Surgery, Nemours Cardiac Center, Alfred I duPont Hospital for Children, Wilmington, DE, USA
| | - Steven Schwartz
- Division of Cardiac Critical Care Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Girish Shirali
- Heart Center, Children's Mercy Hospital, Kansas City, MO, USA
| | - Lloyd Tani
- Division of Pediatric Cardiology, University of Utah and Primary Children's Hospital, Salt Lake City, UT, USA
| | - James Tweddell
- Division of Pediatric Cardiac Thoracic Surgery, Cincinnati Children's Hospital and Medical Center (Posthumous), Cincinnati, OH, USA
| | - Michelle Gurvitz
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
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Comparison of Intraoperative and Discharge Residual Lesion Severity in Congenital Heart Surgery. Ann Thorac Surg 2022; 114:1731-1737. [PMID: 35398038 DOI: 10.1016/j.athoracsur.2022.02.081] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Revised: 02/10/2022] [Accepted: 02/22/2022] [Indexed: 12/31/2022]
Abstract
BACKGROUND While the predischarge technical performance score (DC-TPS) is significantly associated with outcomes after congenital cardiac surgery, the utility of the intraoperative TPS (IO-TPS) remains unknown. METHODS This was a single-center retrospective review of consecutive patients who underwent congenital cardiac surgery from January 2011 to December 2019. Intraoperative and predischarge echocardiograms were used to assign IO-TPS and DC-TPS, respectively, for each index operation (class 1, no residua; class 2, minor residua; class 3, major residua). Anatomic modules identifying the principal residual lesion were assigned to all class 2/3 patients. Overall and module-specific TPS comparisons were made. Multivariable regression models with IO-TPS and DC-TPS as separate predictors of postoperative outcomes were compared. RESULTS Of 6201 patients, overall agreement between IO-TPS and DC-TPS was observed in 4251 patients (68.6%); scores were likelier to be worse at discharge (P < .001). Paired comparative analyses revealed that among patients with at least class 2 atrioventricular and semilunar valve residua, IO-TPS was likelier to worsen than improve (both P < .001). Class 3 patients had a higher risk of in-hospital/early mortality (IO-TPS: odds ratio, 7.5; 95% CI, 2.4-23; DC-TPS: odds ratio, 6.6; 95% CI, 3.0-15), postdischarge/late mortality (IO-TPS: hazard ratio [HR], 3.1, 95% CI, 1.3-7.1; DC-TPS: HR, 2.3; 95% CI, 1.2-4.4), and late unplanned reintervention (IO-TPS: HR, 2.8; 95% CI, 1.9-4.0; DC-TPS: HR, 3.4; 95% CI, 2.8-4.2) vs class 1 (all P < .05). IO- and DC-TPS models were equivalent fits for predicting early and late mortality; the latter was a marginally better fit for late reintervention. CONCLUSIONS IO-TPS and DC-TPS are both important adjuncts for quality improvement in congenital cardiac surgery.
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Sengupta A, Gauvreau K, Kohlsaat K, Colan SD, Newburger JW, Del Nido PJ, Nathan M. Long-Term Outcomes of Patients Requiring Unplanned Repeated Interventions After Surgery for Congenital Heart Disease. J Am Coll Cardiol 2022; 79:2489-2499. [PMID: 35738709 DOI: 10.1016/j.jacc.2022.04.027] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 03/25/2022] [Accepted: 04/04/2022] [Indexed: 12/01/2022]
Abstract
BACKGROUND Unplanned catheter-based or surgical reinterventions after congenital heart operations are independently associated with operative mortality and increased postoperative length of stay. OBJECTIVES This study assessed the long-term outcomes of transplant-free survivors of hospital discharge requiring predischarge reinterventions after congenital cardiac surgery. METHODS Data from patients who required predischarge reinterventions in the anatomic area of repair after congenital cardiac surgery and survived to hospital discharge at a quaternary referral center from January 2011 to December 2019 were retrospectively reviewed. Previously published echocardiographic criteria were used to assess the severity of persistent residual lesions at discharge (Grade 1, no residua; Grade 2, minor residua; and Grade 3, major residua). Outcomes included postdischarge (late) mortality or transplant and unplanned reintervention. Associations between predischarge residual lesion severity and outcomes were assessed by using Cox or competing risk models, adjusting for baseline patient characteristics, case complexity, and preoperative risk factors. RESULTS Among the 408 patients who met entry criteria, there were 58 (14.2%) postdischarge deaths or transplants and 208 (51.0%) late reinterventions at a median follow-up of 3.0 years (IQR: 1.1-6.8 years). Greater predischarge residual lesion severity was associated with worse transplant-free survival and freedom from reintervention (both, P < 0.05). On multivariable analyses, Grade 3 patients had an increased risk of postdischarge mortality or transplant (HR: 4.8; 95% CI: 2.0-11; P < 0.001) and late reintervention (subdistribution HR: 2.1; 95% CI: 1.4-3.1; P < 0.001) vs Grade 1 patients. CONCLUSIONS Among transplant-free survivors requiring predischarge reinterventions after congenital cardiac surgery, those with persistent major residua have significantly worse long-term outcomes. These high-risk patients warrant closer surveillance.
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Affiliation(s)
- Aditya Sengupta
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Massachusetts, USA.
| | - Kimberlee Gauvreau
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA; Department of Biostatistics, Harvard School of Public Health, Boston, Massachusetts, USA
| | - Katherine Kohlsaat
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Steven D Colan
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA; Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
| | - Jane W Newburger
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA; Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
| | - Pedro J Del Nido
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Massachusetts, USA; Department of Surgery, Harvard Medical School, Boston, Massachusetts, USA
| | - Meena Nathan
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Massachusetts, USA; Department of Surgery, Harvard Medical School, Boston, Massachusetts, USA
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Nathan M, Levine JC, Van Rompay MI, Lambert LM, Trachtenberg FL, Colan SD, Adachi I, Anderson BR, Bacha EA, Eckhauser A, Gaynor JW, Graham EM, Goot B, Jacobs JP, John R, Kaltman JR, Kanter KR, Mery CM, LuAnn Minich L, Ohye R, Overman D, Pizarro C, Raghuveer G, Schamberger MS, Schwartz SM, Narasimhan SL, Taylor MD, Wang K, Newburger JW. Impact of Major Residual Lesions on Outcomes After Surgery for Congenital Heart Disease. J Am Coll Cardiol 2021; 77:2382-2394. [PMID: 33985683 PMCID: PMC8245007 DOI: 10.1016/j.jacc.2021.03.304] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2020] [Revised: 03/04/2021] [Accepted: 03/22/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Many factors affect outcomes after congenital cardiac surgery. OBJECTIVES The RLS (Residual Lesion Score) study explored the impact of severity of residual lesions on post-operative outcomes across operations of varying complexity. METHODS In a prospective, multicenter, observational study, 17 sites enrolled 1,149 infants undergoing 5 common operations: tetralogy of Fallot repair (n = 250), complete atrioventricular septal defect repair (n = 249), arterial switch operation (n = 251), coarctation or interrupted arch with ventricular septal defect (VSD) repair (n = 150), and Norwood operation (n = 249). The RLS was assigned based on post-operative echocardiography and clinical events: RLS 1 (trivial or no residual lesions), RLS 2 (minor residual lesions), or RLS 3 (reintervention for or major residual lesions before discharge). The primary outcome was days alive and out of hospital within 30 post-operative days (60 for Norwood). Secondary outcomes assessed post-operative course, including major medical events and days in hospital. RESULTS RLS 3 (vs. RLS 1) was an independent risk factor for fewer days alive and out of hospital (p ≤ 0.008) and longer post-operative hospital stay (p ≤ 0.02) for all 5 operations, and for all secondary outcomes after coarctation or interrupted arch with VSD repair and Norwood (p ≤ 0.03). Outcomes for RLS 1 versus 2 did not differ consistently. RLS alone explained 5% (tetralogy of Fallot repair) to 20% (Norwood) of variation in the primary outcome. CONCLUSIONS Adjusting for pre-operative factors, residual lesions after congenital cardiac surgery impacted in-hospital outcomes across operative complexity with greatest impact following complex operations. Minor residual lesions had minimal impact. These findings may provide guidance for surgeons when considering short-term risks and benefits of returning to bypass to repair residual lesions.
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Affiliation(s)
- Meena Nathan
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Massachusetts, USA; Department of Surgery, Harvard Medical School, Boston, Massachusetts, USA.
| | - Jami C Levine
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA; Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
| | - Maria I Van Rompay
- HealthCore, New England Research Institutes, Watertown, Massachusetts, USA
| | - Linda M Lambert
- Division of Pediatric Cardiology, Primary Children's Hospital, University of Utah, Salt Lake City, Utah, USA
| | | | - Steven D Colan
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA; Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
| | - Iki Adachi
- Division of Congenital Heart Surgery, Texas Children's Hospital, Houston, Texas, USA
| | - Brett R Anderson
- Division of Pediatric Cardiology, NewYork-Presbyterian/Morgan Stanley Children's Hospital, Columbia University Irving Medical Center, New York, New York, USA
| | - Emile A Bacha
- Division of Cardiothoracic Surgery, NewYork-Presbyterian/Morgan Stanley Children's Hospital, Columbia University Irving Medical Center, New York, New York, USA
| | - Aaron Eckhauser
- Division of Pediatric Cardiothoracic Surgery, Primary Children's Hospital, University of Utah, Salt Lake City, Utah, USA
| | - J William Gaynor
- Division of Cardiac Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Eric M Graham
- Division of Pediatric Cardiology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Benjamin Goot
- Division of Pediatric Cardiology, Children's Wisconsin, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Jeffrey P Jacobs
- Division of Cardiac Surgery, Johns Hopkins All Children's Hospital, St. Petersburg, Florida, USA; Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Florida, Gainesville, Florida, USA
| | - Rija John
- Division of Congenital Heart Surgery, Texas Children's Hospital, Houston, Texas, USA
| | - Jonathan R Kaltman
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, Maryland, USA
| | - Kirk R Kanter
- Division of Pediatric Cardiac Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Carlos M Mery
- Texas Center for Pediatric and Congenital Heart Disease, Dell Children's Medical Center, University of Texas Dell Medical School, Austin, Texas, USA
| | - L LuAnn Minich
- Division of Pediatric Cardiology, Primary Children's Hospital, University of Utah, Salt Lake City, Utah, USA
| | - Richard Ohye
- Division of Pediatric Cardiac Surgery, C.S. Mott Children's Hospital, Ann Arbor, Michigan, USA
| | - David Overman
- Division of Cardiovascular Surgery, Children's Minnesota, Mayo Clinic-Children's Minnesota Cardiovascular Collaborative, Minneapolis, Minnesota, USA
| | - Christian Pizarro
- Division of Cardiac Surgery, Nemours Cardiac Center, Alfred I duPont Hospital for Children, Wilmington, Delaware, USA
| | - Geetha Raghuveer
- Heart Center, Children's Mercy Hospital, Kansas City, Missouri, USA
| | - Marcus S Schamberger
- Division of Pediatric Cardiology, Riley Hospital for Children, Indiana University, Indianapolis, Indiana, USA
| | - Steven M Schwartz
- Division of Cardiac Critical Care Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Shanthi L Narasimhan
- Division of Pediatric Cardiology, Masonic Children's Hospital, Minneapolis, Minnesota, USA
| | - Michael D Taylor
- Division of Pediatric Cardiology, Cincinnati Children's Hospital and Medical Center, Cincinnati, Ohio, USA
| | - Ke Wang
- HealthCore, New England Research Institutes, Watertown, Massachusetts, USA
| | - Jane W Newburger
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA; Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
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Qi L, Ma K, Zhang B, Rui L, Lin Y, Wang G, Li S. Pediatric Mitral Regurgitation: Standardized Repair-Oriented Strategy With Leaflet Plication. Semin Thorac Cardiovasc Surg 2020; 32:1002-1012. [PMID: 32505798 DOI: 10.1053/j.semtcvs.2020.05.029] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Accepted: 05/29/2020] [Indexed: 11/11/2022]
Abstract
To introduce a standardized strategy and reproducible procedures of mitral repair for mitral regurgitation in the pediatric population with leaflet plication as a principal technique. Consecutive patients who had undergone mitral repair by our standardized repair-oriented strategy in our institution from January 2016 to December 2019 were included retrospectively. The standardized repair strategy included 3-step inspections and repair from the subvalvular to leaflet, and then to the annular level. The main surgical techniques included chordae detachment, papillary muscle splitting, leaflet plication, and posterior annuloplasty. The indication for leaflet plication was that the distance between 2 adjacent chordae tendineae was greater than 4 mm. A total of 113 patients were enrolled. During 22.6-month (range, 2-50 months) follow-up period, primary endpoint was documented in 15 (13.3%) patients, including 1 (0.9%) death, 0 transplantation, and 14 (12.4%) functional mitral failure. Freedom form primary endpoints at 6 months, 1 year, and 3 years was 94.7%, 94.7%, and 82.3%, respectively. Significant independent predictors of functional mitral valve failure were younger age (hazard ratio [HR], 0.28; 95% confidence interval [CI], 0.04-0.72; P = 0.037) and ischemic mitral regurgitation (MR) (HR, 24.34; 95% CI, 4.52-47.33; P < 0.001). Leaflet plication was significantly associated with well-functioned mitral valve (HR, 7.42; 95% CI, 2.35-30.54; P = 0.004). Compared with nonischemic MR group, ischemic MR group was noted with higher occurrence of primary endpoint events (11/28 vs 4/85, P < 0.001). The short- to mid-term outcomes of standardized mitral repair technique with leaflet plication were favorable, among which, however, repair for mitral regurgitation with ischemic lesions is comparatively challenging.
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Affiliation(s)
- Lei Qi
- Department of Cardiac Surgery, Paediatric Cardiac Surgery Center, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Disease, Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, PR China
| | - Kai Ma
- Department of Cardiac Surgery, Paediatric Cardiac Surgery Center, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Disease, Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, PR China
| | - Benqing Zhang
- Department of Cardiac Surgery, Paediatric Cardiac Surgery Center, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Disease, Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, PR China
| | - Lu Rui
- Department of Cardiac Surgery, Paediatric Cardiac Surgery Center, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Disease, Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, PR China
| | - Ye Lin
- Department of Cardiac Surgery, Paediatric Cardiac Surgery Center, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Disease, Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, PR China
| | - Guanxi Wang
- Department of Cardiac Surgery, Paediatric Cardiac Surgery Center, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Disease, Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, PR China
| | - Shoujun Li
- Department of Cardiac Surgery, Paediatric Cardiac Surgery Center, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Disease, Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, PR China.
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